We report a rare case of spontaneous rupture of a thyroid nodule causing extensive soft tissue hematoma involving the laryngopharyngeal, neck, and chest regions in a 41-year-old healthy woman. Spontaneous hematoma secondary to a thyroid nodule is a rare occurrence. Hematoma usually tends to be secondary to blunt cervical trauma, fine needle aspiration for cytology, and usage of anticoagulants such as heparin or warfarin. It is crucial to assess the patient’s condition and airway in managing a case of spontaneous hematoma secondary to a ruptured thyroid nodule as this would determine the subsequent management. In this case, the patient presented with no obstructive signs or symptoms, and thus was managed conservatively. The hematoma subsequently resolved spontaneously.

Background: Tonsillectomy is one of the commonest otolaryngological procedures performed. Multiple reports have demonstrated the safety of ambulatory (outpatient) pediatric Tonsillectomy, however Post-tonsillectomy hemorrhage remains the most serious complication of tonsillectomy.
Patients and methods: In this work, we analyzed different parameters including patient’s age, gender, type of surgery “Tonsillectomy or Adenotonsillectomy”, technique “Cold dissection or Bipolar”, evidence of tonsillar bed infection and pre-operative hemoglobin level in two groups of patients indicated for tonsillectomy. One group of 80 patients didn’t suffer from posttonsillectomy bleeding as a control group; the other of 20 patients having secondary post-tonsillectomy bleeding.
Results: According to our statistical analysis and data, no significant difference between the two groups regarding the occurrence of secondary post-tonsillectomy in the following parameters: patient’s age, gender, type of surgery “Tonsillectomy or Adenotonsillectomy” and preoperative hemoglobin level.
Conclusion: However there was higher incidence of secondary post tonsillectomy bleeding in patients operated by bipolar scissors. Also evidence of tonsillar bed infection raises the possibility of secondary post-tonsillectomy bleeding occurrenc.

Background Behcet’s disease (BD) is a rare immune-mediated small-vessel systemic vasculitis that often presents with mucous membrane ulceration and ocular problems. Alajouanine and colleagues first described inner ear involvement in BD in 1961. The cochlea is more frequently involved than the vestibular labyrinth or the central vestibular tracts. Hearing is commonly impaired in BD and rates vary between 24 and 62%.
Objective The current study investigated the incidence, relationship, and characteristics of audiovestibular disturbances in patients with BD compared with age and sex-matched healthy individuals.
Patients and methods The participants of this prospective study classified into two groups. The study group consisted of 15 patients (six men and nine women) with BD and the control group consisted of 15 healthy volunteers (five men and 10 women) without otological symptoms. A wide range of tests were conducted; all patients were evaluated by conventional pure-tone audiometry (0.25–8.0 kHz), high-frequency audiometry (8.0–16.0 kHz), and vestibular test battery in terms of bithermal caloric test and computerized dynamic posturography testing.
Results There was no significant differences between the two groups in terms of sex and age. Abnormalities of the pure-tone audiometry showed that 34% of patients demonstrated variable degrees of sensorineural hearing loss, while 60% of patients demonstrated abnormal audiograms at the high-frequency audiometry. In terms of vestibular assessment, 34% of patients demonstrated abnormalities at the caloric test, while 47% demonstrated abnormalities at the computerized dynamic posturography testing.
Conclusion The outcome of this study confirms the association between the inner ear dysfunction and the BD. Inner ear dysfunction in BD could be attributed to the presence of vasculitis or neuropathy that could happen on top of chronic inflammation process associated with BD. Therefore, patients with BD should be regularly subjected to otolaryngological evaluation to diagnose and for follow up of any audiovestibular involvement.

Our aim was to evaluate the function and take rate of the butter cartilage technique (BCT) for reconstruction of small-sized and medium-sized tympanic membrane (TM) perforation by comparing it with temporalis fascia (TF). Repair of the TM was carried out in 40 patients with unilateral Chronic Suppurative Otitis Media (CSOM) with small-sized and medium-sized TM perforation. The patients were divided into two groups: group ‘A’, in which the BCT was used, and group ‘B’, in which TF graft was used. During the follow-up period, we found that the graft take-up rate was 90% in the BCT, whereas it was not complete in TF cases. There was marked improvement in hearing in both groups. We concluded that the BCT is optimal in the reconstruction of small-sized and medium-sized TM perforation because it is excellent to obtain high take rate with good hearing results.

Background Tinnitus associated with single-sided deafness (SSD) is frequent and often incapacitating, and is difficult to treat. Numerous studies have reported the suppression of tinnitus by electrical stimulation of the acoustic pathway through a cochlear implant (CI), with a low risk of worsening of tinnitus after implantation.
Objective The main aim of this study was to demonstrate the effectiveness of CI as a treatment option in patients with SSD and incapacitating tinnitus.
Patients and methods We studied the tinnitus-suppression effect of CI in a series of 13 patients with unilateral profound sensorineural hearing loss (SSD), associated with incapacitating tinnitus with normal hearing in the contralateral ear. Tinnitus impact was measured with the Tinnitus Handicap Inventory (THI), and tinnitus severity was measured with the Tinnitus Rating Scale (TRS) before and after CI.
Results Thirteen patients were enrolled in this study, eight men and five women, ranging in age from 24 to 60 years with a mean±SD of 40±10 years. Mean scores for THI and TRS were obtained preoperatively and at 1 and 3 months postoperatively after activation of the CI. Mean scores for the THI total scores ranged from 79.6±7 preoperatively to 12±13.5 at 3 months postoperatively. Mean scores for the TRS ranged from 4.53±0.5 preoperatively to 1.46±0.5 at 3 months postoperatively. The postoperative THI and TRS improved significantly as compared with the baseline preoperative scores (P<0.005).
Conclusion The outcome of the current study supports the belief that CI is not only a treatment option for hearing loss in SSD but also a treatment option to suppress tinnitus.

Objective This study aimed to compare the outcomes of powered turbinoplasty with those of powered turbinectomy.
Materials and methods Forty patients suffering from hypertrophied inferior turbinate that resisted ordinary medical treatment were randomly divided into two equal groups. One group was managed with powered turbinoplasty and the other with powered turbinectomy. The patients were followed up for 6 weeks postoperatively.
Results After 6 weeks the total success in reducing the size of the turbinate and postoperative blood clots was the same (100%) for both groups but it was 100% for powered turbinoplasty and 80% for powered turbinectomy in the occurrence of postoperative crustations.
Conclusion Powered turbinoplasty is a promising surgical procedure for inferior turbinate surgery. This procedure achieves optimum turbinate reduction with less complications in patients with respect to bleeding, occurrence of crustations, blood clots, and nasal discharge postoperatively.

Aim The aim of this study was to evaluate the effect of edge frequency on speech recognition after nonlinear frequency compression (NFC) using Arabic consonant speech discrimination lists.
Patients and methods The study was conducted on 20 adult literate patients with bilateral steep-slope high-frequency sensory–neural hearing loss. Patients were subjected to history taking, ear examination, puretone audiometry, and threshold equalizing noise (HL) test to estimate cochlear dead regions. They were divided into four groups according to the edge frequency. Speech recognition was evaluated using modified Arabic consonant discrimination lists before and after amplification with NFC at three settings that differed in cutoff frequency of compression using the same hearing aid. Free field aided thresholds were obtained in every setting.
Results Patients showed improvement in aided thresholds when the cutoff frequency was lowered. Speech recognition evaluation showed that the extent of dead regions has a marked impact on patients’ speech recognition score. Patients with the lowest edge frequency obtained the worst speech recognition score and least benefit from lowering the cutoff frequency, unlike those patients with the highest edge frequency who had better speech recognition and benefitted more from the highest cutoff frequency.
Conclusion Identifying edge frequency in NFC is important, especially in those patients with steep-slope configuration, as the lower the edge frequency, the poorer the performance. In contrast, satisfactory amplification is reached when the cutoff frequency is at or near the edge frequency.

Objective To assess the effect of topical vancomycin on the prevention of recurrent sinonasal polyposis after functional endoscopic sinus surgical procedure.
Design, setting, and participants A triple-blind, randomized clinical trial of patients aged 18–70 years with sinonasal polyposis whose nasal swab results were positive for Staphylococcus aureus and were candidates for functional endoscopic sinus surgical procedure at Besat Hospital, Hamadan University of Medical Sciences, from September 2014 to September 2015.
Interventions Patients were randomly assigned to receive a solution of normal saline including 1 g/l vancomycin or a solution of normal saline alone (placebo). Patients were asked to irrigate their nose with 20 ml of the prepared solution three times a day for 8 weeks.
Main outcomes and measure The recurrent polyposis and reinfection with S. aureus at 2, 4, and 6 months after sinus surgery.
Results Of 118 patients identified, 35 patients whose nasal swab results were positive for S. aureus remained for analysis, and of those, 18 patients were allocated to the placebo group and 17 to the vancomycin group. There was no statistically significant but clinically important difference in the severity of recurrent postoperative polyposis between the two groups. The recurrence rate of postoperative sinonasal polyposis was clinically different between the two groups, although the difference was not statistically significant. The proportion of reinfection with S. aureus in the second month after surgery was 11/18 (61.1%) in the control group versus 3/17 (17.6%) in the vancomycin group (P=0.015). No significant drug adverse effect was reported by the patients.
Conclusion and relevance This trial indicated that topical vancomycin is a safe drug with no important adverse effects that may reduce the recurrent postoperative polyposis. However, more evidence based on large clinical trials is required to justify the efficacy of topical vancomycin for preventing postoperative polyposis.

Importance Management of saddle nose deformity needs to be directed toward diagnosing its etiology and its treatment.
Objective The aim of this study was to propose a simple classification system for saddle nose deformity that depends on pathologic grading and anatomic reconstruction.
Setting This study was conducted at a university-affiliated tertiary hospital.
Study design The study design was a retrospective chart review.
Patients and methods Patients with saddle nose deformity presenting from 2012 to 2014 were reviewed. The patients were classified according to the septal condition as follows: grade 1, saddle nose due to pathology other than septal collapse (dorsum over-resection, familial, or racial); grade 2, septum is collapsed but can be fixed by means of bone grafts or septal replacement grafts; and grade 3, patients need cartilaginous septum reconstruction.
Results The study included 32 patients, 20 female and 12 male, with a mean age of 27 years. Eleven cases were of grade 1 and were managed with dorsal grafts (septal cartilage in two, conchal cartilage in two, and diced cartilage in fascia in seven cases). Sixteen cases were of grade 2, and all were post-traumatic primary cases. Bone grafts to straighten and stabilize the broken septum were used in 13 cases, and septal replacement grafts were used in three cases. Five cases were of grade 3 and required replacement of septal L-strut that was concealed with diced cartilage in fascia. Columellar strut was used in all cases.
Conclusion Diagnosis and management of saddle nose deformity should depend on identifying the etiology of each case and classifying them into cases due to correctable septal pathology that can be managed with straightening the septum, or those due to missing septum that need septal reconstruction, and those due to low dorsum without septal pathology that can be simply corrected with dorsal grafts. Using this anatomical approach we are trying to achieve a strong esthetic pleasing functioning nose.

Objective The aim of this study was to explore the outcome of hearing aid amplification in children with auditory neuropathy spectrum disorder (ANSD) using speech P1 cortical auditory evoked potential (P1-CAEP).
Study design Forty-five children were divided into three groups: the ANSD group (n=15), the sensorineural hearing loss (SNHL) group (n=15), and the normal hearing group (n=15). The ANSD group had a mean age of 48.2 (±29.4) months and included children with moderate-to-severe hearing loss, a history of bilateral hearing aid use for at least 6 months, and absence of comorbid disorders. The SNHL group was closely matched to the ANSD group. Verification of hearing aids was carried out twice with 6 months of interval and included evaluation of aided sound field and P1-CAEP, and evaluation using the Arabic version of the Infant Toddler Meaningful Auditory Integration Scale (IT-MAIS). The P1-CAEPs were elicited using the temporally modified synthetic ‘ba’ and ‘da’ syllables.
Results In the initial evaluation, 80% of ANSD children showed P1 response to the ‘ba’ stimulus and 87% of children to the ‘da’ stimulus. Only one child from the SNHL group did not show P1-CAEP responses to the ‘da’ stimulus. The latency of P1 was prolonged in both groups compared with the normal hearing loss group. At 6-month evaluation, the P1-CAEP latencies improved equally in the ANSD and SNHL groups. Children with absent responses persisted to have absent responses. The mean IT-MAIS scores was initially 45.5 (±20) in the ANSD group and 79 (±9) in the SNHL group and increased after 6 months in both groups. The IT-MAIS scores negatively correlated with the P1-CAEP latency in the two evaluation sessions and positively correlated with the age of hearing aid fitting.
Conclusion Around 50% of ANSD children demonstrated benefit from amplification. They showed evidence of normal central auditory maturation and progress in auditory skill development. Longitudinal P1 recording is recommended in the comprehensive audiological test battery in ANSD population using temporally modified speech stimuli.

The rarity of lethal midline granuloma and lack of knowledge by the majority of clinicians about this disease makes this disease a difficult entity to diagnose. Nonspecific symptoms of this disease present obstacles in correct diagnosis and lead to a delay in proper treatment. Surgeons play a limited role in this condition. We present a case report of a 38-year-old man with this rare condition.

Background Otosclerosis is a primary localized disease of the bony otic capsule that is mainly localized to the stapedial footplate. Stapedotomy is the treatment of choice. The effect of stapes surgery on otoacoustic emissions is not sufficiently known.
Objectives The aim of the present study was to assess changes in the middle ear dynamic characteristics, and to evaluate distortion product otoacoustic emissions (DPOAEs) in otosclerosis. Moreover, the study aimed to evaluate DPOAEs before and after stapes surgery.
Patients and methods A total of 20 patients with otosclerosis and undergoing stapedotomy surgery were included in the study. Assessment was performed preoperatively, 1 week, 1 month, and 6 months postoperatively by using pure-tone average, tympanometry, and DPOAE.
Results Significant improvement in the air–bone gap by pure-tone average was reported at 1 week and 1 month postoperatively, whereas 6 months postoperative hearing threshold remained the same as that of 1 month postoperative. The difference between preoperative and postoperative detection of DPOAE was not significant.
Conclusion Conventional pure-tone audiometry remains the choice for evaluation of stapes surgery in patients of otosclerosis. The use of DPOAEs in the evaluation of a successful stapes surgery requires further studies including a larger number of patients.

Purpose The aim of this study was to evaluate posterior pharyngeal wall augmentation using autologous tragal cartilage graft in patients with velopharyngeal valve insufficiency (VPI) after simple palatoplasty for cleft palate.
Patients and methods This study included 18 patients with postpalatoplasty VPI (grade 2 or 3), with ages ranging from 5 to 14 years. Patients were followed up for 24–48 months postoperatively. Percent of speech intelligibility and grade of closure of velopharyngeal valve with nasopharyngoscope were evaluated preoperatively and postoperatively.
Results Statistically significant improvement in grade of closure of velopharyngeal valve (P = 0.001) and percent of intelligibility (P = 0.001) was found after surgery.
Conclusion Augmentation of the posterior pharyngeal wall using tragal cartilage is a safe technique, with generally good surgical and phoniatric outcomes in the management of pediatric patients with grades 2 and 3 VPI after simple palatoplasty to overcome hypernasality.

Aim and background Intranasal transsphenoidal access to the sella turcica for removing pituitary gland tumors has been known since the beginning of the last century. It can be done either endoscopic or microscopic. Postoperative nasal complications may happen. The purpose of this study was to assess the frequency of chronic oronasal alterations.
Methodology 33 patients who had previously undergone adenomectomy with a hypophyseal transsphenoidal approach using either the endoscopic or the direct transnasal microscopic technique; these patients were operated in different neurosurgical units. Assessement of nasal complications after 6 months was done.
Results 33 patients among them 18 patients were done by endoscopy and the other 15 were done by microscopy. No postoperative nasal complications in the endoscopy group 6 months postoperative while it is present in 3 cases of the microscopic group after the same time.
Conclusion Direct transnasal approach provides safe transsphenoidal access to the sella with a very low rate of nasal complications.

Background The evaluation of swallowing disorders and their rehabilitative modalities is an important topic. The benefit to the patient, in terms of improvement in quality of life, cannot be underestimated. Bedside tests might be used to identify patients with oropharyngeal dysphagia and to identify those who are at a risk for aspiration.
Aim The aim of the present study was to evaluate the validity and reliability of the Gugging Swallowing Screening (GUSS) test for the detection of aspiration and swallowing abnormalities in dysphagic Egyptian patients. This helps in better management.
Study design The present study was a comparative, cross-sectional study.
Patients and methods A total of 42 patients were referred from the outpatient clinics with a complaint of dysphagia. All patients were evaluated using flexible endoscopic examination of swallowing (FEES) and the GUSS test. The results of these two methods were compared to assess validity. Reliability was approved by the assessment of the Cohen's κ agreement between the two independent raters.
Results The mean age of the patients was 51.6 ± 12.2 years. According to the results of FEES, 28 (66.7%) patients were at a risk for aspiration, whereas 30 (71.4%) patients were rated to be at a risk according to the GUSS test results. According to the cutoff of 14 points, GUSS reached 93.3% sensitivity and 83.3% specificity when compared with FEES. Positive predictive value was 93.3% and negative predictive value was 83.3%. The results of reliability (by comparing the scores of the two raters as regards the degree of severity) showed excellent agreement between the two raters (κ = 0.84, Ρ > 0.05, PO = 91%).
Conclusion GUSS test proved to be an easy, valid, and reliable test to predict the risk for aspiration among the adult Egyptian patients.

Background Many research studies have explained that an auditory processing deficit might be the underlying cause for some forms of reading difficulties. However, deficits affecting other modalities, such as vision might be the other potential contributing factor.
Objectives This research investigated both central auditory processing abilities and the visual pathway in children having scholastic underachievement due to reading difficulties.
Patients and method The study group consisted of 15 children (eight male and seven female) between the age of 5 and 15 years. They had scholastic underachievement due reading difficulties. All children were subjected to a standardized Arabic central auditory test battery for children. It included tests for selective auditory attention, dichotic listening, memory, and temporal processing abilities. Other tests that were administered included electrophysiologic measures, auditory event-related potentials (P300), and visual-evoked potential (P100), as well as the Illinois test of psycholinguistic abilities and screening test for risk for dyslexia to verify reading complains and to assess psycholinguistic abilities.
Results Central auditory test battery that was accompanied by abnormal auditory event-related potentials (P300) revealed abnormal pattern mainly affecting temporal processing and memory abilities. However, some children had additional dichotic listening or selective auditory attention deficit. Abnormal visual-evoked potential (P100) was detected in the majority of children. The Illinois test revealed visual pattern affection in those children.
Conclusion Children with reading difficulties had temporal processing disorder and memory deficit pattern. Furthermore, there was an association between visual affection and reading difficulty that supports multimodality affection in those children. Hence, the remediation program for these children should include both auditory and visual modalities.

Aim The aim of this study was to evaluate the value of the use of endoscopes after a conventional curettage adenoidectomy for detecting any residual adenoid tissue and to determine whether removing any residual, if present, affects the recurrence or not.
Patients and methods Fifty patients were divided randomly into two equal groups. Group A underwent a conventional curettage adenoidectomy, followed by an endoscopic examination of the nasopharynx to detect and remove any residual adenoid tissue. Group B underwent a conventional curettage adenoidectomy only. Both groups were followed up for recurrence of symptomatic adenoid at fixed follow-up intervals at 10 days, 1, 3, and 6 months postoperatively.
Results There was a significant difference in the rate of adenoid recurrence between both groups 6 months postoperatively. Two (8%) patients in group A and nine (36%) patients in group B developed recurrence. The P value was statistically significant at 0.04.
Conclusion Endoscopic examination after a conventional adenoidectomy is a safe and essential step for complete removal of the adenoid, thus reducing the recurrence rate.

There is some debate on the epidemiological data of childhood tinnitus and hyperacusis. It is vital for Audiologists to pay careful attention to minor complaints such as hyperacusis in children to manage them successfully.

Background Professional voice users are a group of people using their voice for earning of their income. One such important profession is that of the Imams of mosques who excessively recite Quran, especially during Ramadan. This excessive reciting during Ramadan puts them in a great risk for vocal problems. The Imams need an assessment and management for their voice to protect them from the expected voice disorders.
Aim The aim of this study was to assess the voice of Imams before and after Ramadan and to study the effect of following the voice hygiene advices during Ramadan on their voice.
Study design This was a cross-sectional study conducted to assess the voice of Imams before and after Ramadan.
Patients and methods The study included 34 Imams. They were divided into two groups: the first group included 17 Imams who received voice hygiene advices before Ramadan, and the second group included 17 Imams who did not receive voice hygiene advices (the control group). All candidates were subjected to two types of assessment: examination using the VHI (the Arabic modification of voice handicapped index) and multidimensional voice program.
Results The group that received voice hygiene advices showed better scores of multidimensional voice program and VHI compared with the control group voice parameters, and some parameters were significantly better or toward normal in post-Ramadan compared with pre-Ramadan assessment.
Conclusion and recommendation Voice hygiene advices should be given to a wide scale of Imams as a protective tool for their voices. Voice hygiene advices should be included in any program of voice therapy.

Syringocystadenoma papilliferum in the middle earWael A AlzamilJanuary-March 2017, 33(1):124-127DOI:10.4103/1012-5574.199403

Syringocystadenoma papilliferum is a rare adnexal tumor of controversial origin that often occurs as a solitary tumor derived from apocrine and eccrine glands. It is more common in children and adolescents and affects the head and neck regions, although occurrences on other anatomical locations have been described. Routine H&E-stained sections revealed cystic epidermal invaginations with papillary projections. The superficial portions of the cyst were lined by stratified keratinizing epithelium, whereas the deeper papillated portion exhibited a double layer of basal-like cells and luminal eosinophilic columnar cells with focal decapitation secretions. A female patient, aged 29 years, presented to us in the outpatient clinic suffering from left earache and hearing loss since the past 3 months, with gradual onset and a slowly progressive course. On examination, we found a left aural polyp, which was firm and grayish in color, but extremely tender on touch. Biopsy for histopathological examination was consistent with a diagnosis of syringocystadenoma papilliferum. The patient received regular follow-up and is doing well with regard to her earache with marked hearing improvement. To conclude, solitary lesions seen in unusual locations generate multiple differential diagnoses and should be confirmed by histopathology in order to exclude other pathologies and define the appropriate therapeutic approach.

Background Birth is a biological process that involves the emergence of an offspring. A seasonal variation in the frequency of births is reported as a universal phenomenon in the human population. In review to outline of birth, newborns may yield seasonality in the occurrence of congenital hearing loss. Congenital hearing loss is one of the most common birth defects affecting ∼3/1000 newborns.
Aim The aim of this study was to rule out seasonality of birth and percentage of hearing loss in early days of newborns.
Patients and methods Seasonality of birth was analyzed across the years and newborns born per month were numbered to surpass the subjective and objective Universal Neonatal Hearing Screening Program before 1 month of age.Combined results of the subjective and objective tests were analyzed and compared to make the final decision as Pass or Refer.
Results Statistical analysis revealed that birth frequency and newborn hearing loss do not follow seasonality pattern.
Conclusion Similarly, there was no correlation between the birth frequency and percentages of newborns with refer impression.

Dichotic integration: is it similar in the elderly and children?Tayseer T Abdel RahmanJanuary-March 2017, 33(1):56-60DOI:10.4103/1012-5574.199400

Background Aging process is associated with central auditory changes, which may explain some understanding difficulties in elderly. It may be evaluated with the dichotic digits (DD) test, a widely used experimental paradigm for studying interhemispheric interactions.
Purpose This study was performed to evaluate dichotic integration ability in the elderly and children populations by comparing it with adults who acted as reference.
Research design The study design was a cross-sectional one. It was conducted in Ain Shams University, Faculty of Medicine, Demerdash Hospital, Audiology Unit, for a period of 4 years. The study comprised 75 participants divided into three groups: the adult group, the elderly group, and the pediatric group.
Data collection and analysis Basic Audiological Evaluation and the DD test in the free recall condition were carried out in all participants.
Results Results of this study suggest that central auditory processing concerning dichotic integration is different in children and elderly individuals when compared with adults. Moreover, there was no significant difference between elderly patients and children. The age had a direct correlation with DD test scores in children, but an inverse correlation in the elderly.
Conclusion Dichotic integration as measured using the DD test is similar in the elderly and children, but in opposite directions with regard to its change with age progress.

Introduction Various open surgical techniques have been previously described for subglottic stenosis. These techniques usually involve steroid injections, endoscopic dilatations, flaps, and placement of intraluminal stents. A retrospective review was conducted on 20 patients with subglottic stenosis who underwent surgical widening using composite nasal septal grafts utilizing a rotated H-shaped cricotracheal split and temporary tracheotomy without stenting. Tracheotomy was performed for patient safety. All patients maintained patent airways with wide subglottic area throughout the follow-up period. All of them were extubated or decannulated 28–33 days after surgery by removing the tracheostomy tubes. All patients started antireflux treatment on the first postoperative day and steroid inhalation 2 weeks after surgery, which was maintained for 3 months. No patients underwent further procedures. All 20 patients were decannulated and were doing well at the time of writing. To conclude, composite nasal septal cartilage grafts with a rotated H-shaped cricotracheal split for subglottic stenosis in selected cases is a viable and effective option.
Context The most common sequel after reconstructive procedures may be restenosis of different degrees. Recurrent narrowing may be due to healing by marked fibrosis, which is a result of postoperative infection, perichondritis in the graft or recipient site, with resorption of the augmenting cartilage graft. Intraluminal stenting predisposes to infection, subperichondrial abscesses, and devitalization of the cartilage graft by friction and infection. Inadequate graft size, thickness, or method of fixation may be other factors for failure.
Aim The aim of the study was to present the indications, surgical technique, and results of composite nasal septal cartilage grafts using a rotated H-shaped cricotracheal split for patients with subglottic stenosis.
Patients and methods This is a retrospective review. A series of 20 patients who underwent composite nasal septal cartilage grafts without stenting from 2009 to 2014 were reviewed. They suffered from subglottic and upper tracheal stenosis: 13 patients had subglottic stenosis due to rhinolaryngeoscleroma (seven male and six female patients), five patients had postintubation upper tracheomalacia and stenosis (one male and four female patients), and two male children had congenital subglottic stenosis. Postoperative data included mortality and morbidity rate, success of decannulation, need for repeat tracheotomy or Montgomery T-tube placement, and number of additional airway procedures.
Results The operative time ranged from 1.5 to 3.25 h with a mean of 2.2 h. Blood loss ranged from 85 to 290 cm3, with a mean of 150 cm3. Hospitalization was 3 days in all patients with discharge on the third postoperative day, except for two children with congenital subglottic stenosis who stayed for 1 week. There were no major complications. Wound infection in two patients around the tracheotomy tube was evident 10 days after surgery, which was well controlled by parentral antibiotic and local antiseptic measures. Chest infection was recorded in five patients as mild to moderate tracheobronchitis, which resolved 1 week after surgery, except for the case of a 53-year-old female patient who progressed to bronchopneumonia after discharge, which resolved after 10 days. Return to normal life activity or work was possible in all patients after 2–3 weeks; however, 14 patients preferred home stay until tube removal. Weaning started 4 weeks after surgery and was successful within 1 week in all patients except for the two children, whose tubes were removed after 2 weeks of gradual weaning. Five patients experienced mild shortness of breath shortly after extubation, which increased with effort. They received steroid inhalation two to three times a day for 2 weeks with improvement in symptoms. During the follow-up period all patients sustained normal breathing, except for seven scleroma patients who after 4–7 months complained of mild dyspnea, which increased slightly with effort and prevailed thereafter. Follow-up flexible laryngoscopy detected mild mucosal edema and little granulation tissue around the grafted area at the time of extubation. These granulations were more evident and encroached slightly on the airway in the five patients who suffered from mild dyspnea shortly after extubation and regressed markedly after 2 weeks of steroid inhalation. There was rapid mucosal healing of nasal septal mucosa and laryngeal mucosa, which was nearly complete at 6 weeks after surgery, with a markedly wide subglottic area. Later on, endoscopic examination detected mild lumen narrowing in seven scleroma patients who complained of mild dyspnea 4–7 months after surgery. These patients showed no more narrowing on endoscopic examination through their subsequent months of follow-up. No other new symptoms developed in the follow-up period. No patient needed further surgical intervention.
Conclusion Composite nasal septal cartilage grafting with a rotated H-shaped cricotracheal split is a viable and successful option for selected cases of laryngotracheal stenosis. The use of a stent with its associated morbidities is avoided with this technique. No additional endoscopic or open procedures were needed in any of the cases; successful decannulation in less than 1 month could be achieved.